Background: The aim of the present study was to analyze incidence, risk factors, and association with long-term outcome of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR).Methods: Six hundred and sixty one consecutive patients undergoing TAVR were prospectively enrolled from January 2016 to December 2017. POD was assessed regularly during ICU-stay using the CAM-ICU test.Results: The incidence of POD was 10.0% (n = 66). Patients developing POD were predominantly male (65%), had higher EuroSCORE II (5.4% vs. 3.9%; P = 0.041) and were more often considered frail (70% vs. 26%; P < 0.001). POD was associated with more peri-procedural complications including vascular complications (19.7 vs. 9.4; P = 0.017), bleeding (12.1 vs. 5.4%; P = 0.0495); stroke (4.5 vs. 0.7%; P = 0.025), respiratory failure requiring ventilation (16.7% vs. 1.8%; P < 0.001), and pneumonia (34.8% vs. 7.1%; P < 0.001). Consequently, patients with POD had significantly longer ICU- (7.9 vs. 3.2 days P < 0.001) and hospital-stay (14.9 vs. 9.0 days; P < 0.001), and higher in-hospital mortality (6.1 vs. 2.1%; P = 0.017). Logistic regression analysis identified male sex (odds ratio (OR) 2.2 [95% confidence interval (CI) 1.2–4.0); P = 0.012], atrial fibrillation [OR 3.0 (CI 1.6–5.6); P < 0.001], frailty [OR 4.3 (CI 2.4–7.9); P < 0.001], pneumonia [OR 4.4 (CI 2.3–8.7); P < 0.001], stroke [OR 7.0 (CI 1.2–41.6); P = 0.031], vascular complication [OR 2.9 (CI 1.3–6.3); P = 0.007], and general anesthesia [OR 2.0 (CI 1.0–3.7); P = 0.039] as independent predictors of POD. On Cox proportional hazard analysis POD emerged as a significant predictor of 2-year mortality [HR 1.89 (CI 1.06–3.36); P = 0.030].Conclusion: POD is a frequent finding after TAVR and is significantly associated with reduced 2-year survival. Predictors of delirium include not only peri-procedural parameters like stroke, pneumonia, vascular complications and general anesthesia but also baseline characteristics as male sex, atrial fibrillation and frailty.

Background: The best management of stable coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is still unclear due to the marked inconsistency of the available evidence. Methods: The REVASC-TAVI registry (Management of Myocardial Revascularization in Patients Undergoing Transcatheter Aortic Valve Implantation With Coronary Artery Disease) collected data from 30 centers worldwide on patients undergoing TAVI who had significant, stable CAD at preprocedural work-up. For the purposes of this analysis, patients with either complete or incomplete myocardial revascularization were compared in a propensity score matched analysis, to take into account of baseline confounders. The primary and co-primary outcomes were all-cause death and the composite of all-cause death, stroke, myocardial infarction, and rehospitalization for heart failure, respectively, at 2 years. Results: Among 2407 patients enrolled, 675 pairs of patients achieving complete or incomplete myocardial revascularization were matched. The primary (21.6% versus 18.2%, hazard ratio‚ 0.88 [95% CI, 0.66–1.18]; P =0.38) and co-primary composite (29.0% versus 27.1%, hazard ratio‚ 0.97 [95% CI, 0.76–1.24]; P =0.83) outcome did not differ between patients achieving complete or incomplete myocardial revascularization, respectively. These results were consistent across different prespecified subgroups of patients (< or >75 years of age, Society of Thoracic Surgeons score > or <4%, angina at baseline, diabetes, left ventricular ejection fraction > or <40%, New York Heart Association class I/II or III/IV, renal failure, proximal CAD, multivessel CAD, and left main/proximal anterior descending artery CAD; all P values for interaction >0.10). Conclusions: The present analysis of the REVASC-TAVI registry showed that, among TAVI patients with significant stable CAD found during the TAVI work-up, completeness of myocardial revascularization achieved either staged or concomitantly with TAVI was similar to a strategy of incomplete revascularization in reducing the risk of all cause death, as well as the risk of death, stroke, myocardial infarction, and rehospitalization for heart failure at 2 years, regardless of the clinical and anatomical situations.

No abstract

Objectives This study aimed to compare hemodynamic characteristics of different self-expanding (SE) and balloon-expandable (BE) transcatheter heart valves (THV) in relation to native aortic annulus anatomy. Background A patient centered THV selection becomes increasingly important as indications for transcatheter aortic valve replacement (TAVR) are extended towards lower risk populations. Methods Hemodynamic parameters including mean gradient (MG), effective orifice area (EOA), Doppler velocity index (DVI), degree of paravalvular regurgitation (PVR) and patient-prosthesis mismatch (PPM) were compared by valve type, label size and in relation to quintiles of native aortic annulus area. Results 2609 patients were treated at 3 centers in Germany with SAPIEN 3 (n = 1146), ACURATE Neo (n = 649), Evolut R (n = 546) or Evolut Pro (n = 268) THV. SE THVs provided superior hemodynamics in terms of larger EOA, higher DVI and lower MG compared to BE THV, especially in patients with small aortic annuli. Severe PPM was less frequent in SE treated patients. The rate of PVR ≥ moderate was comparable for SE and BE devices in smaller annular dimensions, but remarkably lower for BE TAVR in large aortic annular dimensions (> 547.64 mm2) (2% BE THV vs. > 10% for SE THV; p < 0.001). Conclusions Patients with small aortic annular dimensions may benefit hemodynamically from SE THV. With increasing annulus size, BE THV may have advantages since PVR ≥ moderate occurs less frequently. Graphical abstract

Objective: The aim of this study was to evaluate non-hyperemic resting pressure ratios (NHPRs), especially the novel “resting full-cycle ratio” (RFR; lowest pressure distal to the stenosis/aortic pressure during the entire cardiac cycle), compared to the gold standard fractional flow reserve (FFR) in a “real-world” setting.Methods: The study included patients undergoing coronary pressure wire studies at one German University Hospital. No patients were excluded based on any baseline or procedural characteristics, except for insufficient quality of traces. The diagnostic performance of four NHPRs vs. FFR ≤ 0.80 was tested. Morphological characteristics of stenoses were analyzed by quantitative coronary angiography.Results: 617 patients with 712 coronary lesions were included. RFR showed a significant correlation with FFR (r = 0.766, p &lt; 0.01). Diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of RFR were 78% (95% confidence interval = 75; 81), 72% (65; 78), 81% (77; 84), 63% (57; 69), and 86% (83; 89). Relevant predictors for discordance of RFR ≤ 0.89/FFR &gt; 0.8 were LAD lesions, peripheral artery disease, age, female sex and non-focal stenoses. Predictors for discordance of RFR &gt; 0.89/FFR ≤ 0.8 included non-LCX lesions, percent diameter stenosis and previous percutaneous coronary intervention in the target vessel. RFR and all other NHPRs were highly correlated with each other.Conclusion: All NHPRs have a similar correlation with the gold standard FFR and may facilitate the acceptance and implementation of physiological assessments of lesion severity. However, we found ~20% discordant results between NHPRs and FFR in our “all-comers” German cohort.

No abstract

Background: Computed tomography derived Fractional Flow Reserve (CT-FFR) has been shown to decrease the referral rate for invasive coronary angiography (ICA). The purpose of the study was to evaluate the diagnostic performance of CT-FFR compared to hyperemia-free index Resting Full-cycle Ratio (RFR) in patients with relevant aortic stenosis (AS) and intermediate coronary stenosis. Methods: 41 patients with 46 coronary lesions underwent ICA with quantitative coronary angiography (QCA), pressure wire assessment and routine pre-transcatheter aortic valve replacement (TAVR) computed tomography (CT). CT-FFR analysis was performed using prototype on-site software. Results: RFR showed a significant correlation with CT-FFR (Pearson’s correlation, r = 0.632, p < 0.001). On a per-lesion basis, diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CT-FFR were 82.6% (95% CI 68.6–92.2), 69.6% (95% CI 47.1–86.8), 95.7% (95% CI  78.1–99.9), 94.1% (95% CI 69.8–99.1), and 75.9% (95% CI 62.7–85.4), respectively. The optimal cutoff value of the CT-FFR for RFR ≤ 0.89 prediction was 0.815. The area under the receiver curve showed a larger area under the curve for CT-FFR (0.87; 95% CI 0.75–0.98) compared with CTA stenosis of ≥50% (0.54, 95% CI 0.38–0.71), CTA ≥ 70% (0.72, 95% CI 0.57–0.87) and QCA ≥ 50% (0.67, 95% CI 0.52–0.83). Conclusions: CT-FFR assessed by routine pre-TAVR CT is safe and feasible and shows a significant correlation with RFR in patients with AS. CT-FFR is superior to QCA ≥ 50%, CT ≥ 50% and CT ≥ 70% in assessing the hemodynamic relevance of intermediate coronary lesions. Thus, CT-FFR has the potential to guide revascularization in patients with AS.

No abstract